Pearl of Elgin, The

In the surveyor’s words

From the most serious findings on record at Pearl of Elgin, The, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 17, 2026

  Based on interview and record review, the facility failed to administer timely and correct treatment for a resident with a UTI (Urinary Tract Infection). The facility also failed to administer medications as ordered by the provider. This failure resulted in R1 being hospitalized for metabolic encephalopathy and UTI due to not receiving the correct antibiotic to treat her UTI. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for UTI in the sample of 5.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, dementia, urinary tract infection, and congestive heart failure. […]

• Actual harm, isolatedF689Oct 19, 2022

  Based on interview and record review, the facility failed to ensure 2 staff were present during resident care to prevent resident injury for 2 residents (R9 and R77), and failed to ensure 2 staff were present for a resident transfer for 1 resident (R46). This failure resulted in R77 rolling out of bed, sustaining subdural hematomas requiring emergency care and hospitalization . This applies to 3 of 25 residents (R9, R77, R46) reviewed for safety/supervision in the sample of 25. The findings include: R77's Facility assessment dated [DATE], 5/23/22, and 8/22/22 showed R77 being [AGE] years old, being cognitively intact, and needing two-person assistance with bed mobility, transfers, dressing, toileting, and bathing. […]

• Actual harm, isolatedF692Feb 18, 2021

  Based on interview and record review, the facility failed to identify and inform the physician of a resident's decreased intake and urinary output. This failure resulted in a change of mental status and the resident being hospitalized in the intensive care unit with severe dehydration and malnutrition. This applies to 1 of 3 residents (R1) reviewed for dehydration and malnutrition in a total sample of 13 residents. The findings include: According to the Electronic Health Record (EHR) R1 had [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE]. The admission Minimum Data Set ((MDS) dated [DATE] showed R1 needed extensive assistance of one person for bed mobility, transfers, dressing, eating, toilet use, and hygiene. […]

• No harm, potential for more than minimal, widespreadF804Aug 29, 2026

  Based on observations, interviews and record reviews, the facility failed to serve hot foods at meals at palatable temperatures. This applies to all 125 residents receiving oral diets at the facility.The findings include: Facility Resident Listing Report, dated 8/28/26, shows the facility census was 125 residents.On 8/30/26 at 2:17 PM, V1 (Administrator) stated all residents were receiving oral diets in the facility.1. On 8/28/26 at 12:30 PM, V14 (Food Service Director) stated he sometimes received cold food complaints from residents who received their trays in their rooms. On 8/28/26 at 12:29 PM a lunch test tray was plated in the kitchen and placed on the 100 hall meal cart. At 12:58 PM the last tray was served to residents in the 100 hall. […]

• No harm, potential for more than minimal, widespreadF880Aug 22, 2024

  Based on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during provisions of care with R59. The facility also failed to follow their water management plan for Legionella. This has the potential to affect all 121 residents residing in the facility. The findings include: 1. R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of thoracic vertebra (T7-T8), wedge compression of first lumbar vertebrae, dementia, and cerebrovascular disease. R59's MDS (Minimum Data Set) dated July 8, 2024, showed R59 had cognitive impairment and was dependent on staff for toileting hygiene. […]